Forensic Aspects of Schizophrenia Care

Essential Concepts

Physicians have obligations not only toward the welfare of their patients but also toward the commonwealth of the citizens in their community. Protecting the public from harm from psychotic patients is such an obligation that is mandated by state laws.
Involuntary hospitalization and treatment is necessary and allowed for patients with psychosis who are dangerous to others, to themselves, or who are incapacitated to the point that they can no longer take care of themselves.
Evaluations for capacity to consent to or refuse medical treatment follow the same principles for patients with schizophrenia as for any other patients.
Lack of appropriate paternalism in health care can result in patient abandonment.

“… nor shall any State deprive any person of life, liberty, or property, without due process of law.”

—Fourteenth Amendment to the United States Constitution

A fundamental right in our society is that citizens have the “right to be let alone,” in Supreme Court Justice Louis Brandeis’s words. In the medical arena, this means that (competent) patients can refuse even life saving treatments. However, the public also has the right to be protected, and physicians have obligations toward the welfare of the general public as well. In disorders that potentially affect a community, the personal perspective is important but not sufficient to ignore community interests. Just as patients might not have the right go untreated and spread tuberculosis, they might not have the right to endanger other people while psychotic.

VIOLENCE

A link between psychosis and violence has been much debated and at times even discounted, probably because of efforts to decrease stigma. I think it defies common sense that psychosis would not in certain instances increase the risk for violence: it obviously does. The most dangerous patients I have encountered come from a small subgroup of persons with schizophrenia: young, substance-using male patients who are antisocial, and suffer from paranoid schizophrenia. When decompensated, these patients are extremely volatile and paranoid, with no impulse control, which makes them dangerous.

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) evaluated the propensity for violence in their sample of almost 1,500 patients. The 6-month prevalence for any act of violence was close to 20% (Swanson et al., 2006). You should note, however, that serious violence (in this study defined as assault resulting in injury, lethal weapon threat or use, or sexual assault) was much less common, 3.6%. Serious violence was associated with positive symptoms, whereas other forms of violence were better predicted by environmental variables. Not surprisingly, negative symptoms had a protective effect.

You must know your legal responsibilities with regard to warning identified victims and protecting them and the public (the so-called duty to warn and protect). To safeguard the public, all states have provisions for committing a patient with schizophrenia who is violent.

Here are some key points to remember to stay safe in your line of work as a psychiatrist treating schizophrenia:

When you work with psychotic patients, remain alert to the possibility of harm from your patient.
Just like you assess the potential for suicide in all patients, you must estimate the risk for immediate violence and the potential for violence in the future. You do this by combining an actuarial approach (past history) with your cross-sectional data (Table 30.1).
Record any history of violence during acute psychosis in your lifetime problem list so the information does not get lost.

Preventing violence is important not just to protect yourself and society but also to combat stigma. Allowing a small
subset of violent persons with schizophrenia to go untreated is a disservice to all patients with schizophrenia who are trying to live peaceful lives.

TABLE 30.1. Clinical Assessment of Aggression^a

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